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Background: Practice facilitators (PFs) coach practices through quality improvement (QI) initiatives aimed at enhancing patient outcomes and operational efficiencies. Practice facilitation is a dynamic intervention that, by design, is tailored to practices' unique needs and contexts. Little research has explored the amount of time PFs spend with practices on QI activities. This short report expands on previously published work that detailed a 12-month practice facilitation intervention as part of the Southeastern Collaboration to Improve Blood Pressure Control (SEC) trial, which focused on improving hypertension control among people living in rural settings in the southeastern USA. This report analyzes data on the time PFs spent to guide 32 primary care practices in implementing QI activities to support enhanced outcomes in patients with high blood pressure., Methods: The SEC trial employed four certified PFs across all practice sites, who documented time spent: (1) driving to support practices; (2) working on-site with staff and clinicians; and (3) communicating remotely (phone, email, or video conference) with practice members. We analyzed the data using descriptive statistics to help understand time devoted to individual and aggregated tasks. Additionally, we explored correlations between practice characteristics and time spent with PFs., Results: In aggregate, the PFs completed 416 visits to practices and spent an average of 130 (SD 65) min per visit driving to and from practices. The average time spent on-site per visit with practices was 87 (SD 37) min, while an average of 17 (SD 12) min was spent on individual remote communications. During the 12-month intervention, 1131 remote communications were conducted with practices. PFs spent most of their time with clinical staff members (n = 886 instances) or with practice managers alone (n = 670 instances) while relatively few on-site visits were conducted with primary care providers alone (n = 15). In 19 practices, no communications were solely with providers. No significant correlations were found between time spent on PF activities and a practices' percent of Medicaid and uninsured patients, staff-provider ratio, or federally qualified health center (FQHC) status., Conclusions: PFs working with practices serving rural patients with hypertension devote substantial time to driving, highlighting the importance of optimizing a balance between time spent on-site vs. communicating remotely. Most time spent was with clinical staff, not primary care providers. These findings may be useful to researchers and business leaders who design, test, and implement efficient facilitation services., Trial Registration: NIH ClinicalTrials.gov NCT02866669 . Registered on 15 August 2016. NHLBI AWARD number: PCS-1UH3HL130691., (© 2023. The Author(s).)

Background: The Lower Limb Assessment Score (LLAS) has only been validated in a paediatric population. The aim of this study was to validate the use of the LLAS in an adult population by: i) evaluating its ability to discriminate between different extents of lower limb hypermobility, ii) establishing a cut-off score to identify lower limb hypermobility, and iii) determining if the LLAS is able to identify Generalised Joint Hypermobility (GJH)., Methods: Participants were recruited across three groups representing varying degrees of hypermobility. They were assessed using the LLAS, Beighton score and clinical opinion. Pearson's correlation coefficient and MANOVA were used to assess between-group differences in the LLAS. The cut-off score was determined using median and inter-quartile ranges and the Receiver Operator Characteristic Curve. The ability of the LLAS to identify GJH was assessed using percent agreement with clinical opinion., Results: One hundred twelve participants aged 18-40 years were recruited. The LLAS distinguished the control from the likely hypermobile and known hypermobile cohorts (both p < 0.001), as well as the likely hypermobile from the known hypermobile cohort (p = 0.003). The LLAS cut-off score for identifying lower limb hypermobility was ≥7/12 with a specificity of 86% and sensitivity of 68%. The LLAS accurately identified those with GJH with high percentage agreement compared to clinical opinion across all cohorts (69-98%)., Conclusions: The LLAS is a valid tool for identifying lower limb specific hypermobility and GJH in adults at a cut-off score of ≥7/12. It demonstrates excellent specificity and moderate sensitivity, and discriminates well between extents of hypermobility.

Background: Students often strategically adopt surface approaches to learning anatomy in order to pass this necessarily content-heavy subject. The consequence of this approach, without understanding and contextualisation, limits transfer of anatomical knowledge to clinical applications. Encouraging deep approaches to learning is challenging in the current environment of lectures and laboratory-based practica. A novel interactive anatomy workshop was proposed in an attempt to address this issue., Methods: This workshop comprised of body painting, clay modelling, white-boarding and quizzes, and was undertaken by 66 health science students utilising their preferred learning styles. Performance was measured prior to the workshop at the mid-semester examination and after the workshop at the end-semester examination. Differences between mid- and end-semester performances were calculated and compared between workshop attendees and non-attendees. Baseline, post-workshop and follow-up surveys were administered to identify learning styles, goals for attendance, useful aspects of the workshop and self-confidence ratings., Results: Workshop attendees significantly improved their performance compared to non-attendees (p = 0.001) despite a difference at baseline (p = 0.05). Increased self-confidence was reported by the attendees (p < 0.001). To optimise their learning, 97% of attendees reported utilising multi-modal learning styles. Five main goals for participating in the workshop included: understanding, strategic engagement, examination preparation, memorisation and increasing self-confidence. All attendees reported achieving these goals. The most useful components of the workshop were body painting and clay modelling., Conclusions: This interactive workshop improved attendees' examination performance and promoted engaged-enquiry and deeper learning. This tool accommodates varied learning styles and improves self-confidence, which may be a valuable supplement to traditional anatomy teaching.

Background: Children with Joint Hypermobility Syndrome (JHS) have reduced knee joint proprioceptive acuity compared to peers. Altered proprioception at end of range in individuals with JHS is hypothesised to contribute to recurrent joint injuries and instability. This study aims to provide the first objective comparison of functional knee joint proprioceptive acuity in hyperextension range compared to early flexion range in children with JHS., Methods: Active, weight-bearing knee joint proprioceptive acuity in both hyperextension and early flexion range was tested with a purpose-built device. Proprioceptive acuity was measured using the psychophysical method of constant stimuli to determine ability to discriminate between the extents of paired active movements made to physical stops. The smallest difference in knee range of motion that the child is able to correctly judge on at least 75% of occasions, the Just Noticeable Difference (JND), was calculated using Probit analysis. Knee pain, muscle strength, amount of physical activity and patient demographic data were collected., Results: Twenty children aged 8-16 years with JHS and hypermobile knees participated. Eleven children demonstrated better proprioceptive acuity in flexion, and 9 in hyperextension (z = 0.45, p = 0.63). Matched pairs t-test found no significant difference in children's ability to discriminate between the same extents of movement in the hyperextension or flexion directions (mean JND difference 0.11°, 95% CI -0.26° - 0.47°, p = 0.545). However, 3 children could not discriminate movements in hyperextension better than chance. Proprioceptive acuity scores were positively correlated between the two directions of movement (r = 0.55, p = 0.02), with no significant correlations found between proprioceptive acuity and age, degree of hypermobility, muscle strength, pain level, amount of physical activity or body mass index centile (r = -0.35 to -0.03, all p ≥ 0.13)., Conclusion: For a group of children with JHS involving hypermobile knees, there was no significant difference between knee joint proprioceptive acuity in early flexion and in hypermobile range when measured by a functional, active, weight-bearing test. Therefore, when implementing a proprioceptive training programme, clinicians should focus training throughout knee range, including into hyperextension. Further research is needed to determine factors contributing to pain and instability in hypermobile range.

Background: Knee pain in children with Joint Hypermobility Syndrome (JHS) is traditionally managed with exercise, however the supporting evidence for this is scarce. No trial has previously examined whether exercising to neutral or into the hypermobile range affects outcomes. This study aimed to (i) determine if a physiotherapist-prescribed exercise programme focused on knee joint strength and control is effective in reducing knee pain in children with JHS compared to no treatment, and (ii) whether the range in which these exercises are performed affects outcomes., Methods: A prospective, parallel-group, randomised controlled trial conducted in a tertiary hospital in Sydney, Australia compared an 8 week exercise programme performed into either the full hypermobile range or only to neutral knee extension, following a minimum 2 week baseline period without treatment. Randomisation was computer-generated, with allocation concealed by sequentially numbered opaque sealed envelopes. Knee pain was the primary outcome. Quality of life, thigh muscle strength, and function were also measured at (i) initial assessment, (ii) following the baseline period and (iii) post treatment. Assessors were blinded to the participants' treatment allocation and participants blinded to the difference in the treatments., Results: Children with JHS and knee pain (n=26) aged 7-16 years were randomly assigned to the hypermobile (n=12) or neutral (n=14) treatment group. Significant improvements in child-reported maximal knee pain were found following treatment, regardless of group allocation with a mean 14.5 mm reduction on the visual analogue scale (95% CI 5.2 - 23.8 mm, p=0.003). Significant differences between treatment groups were noted for parent-reported overall psychosocial health (p=0.009), specifically self-esteem (p=0.034), mental health (p=0.001) and behaviour (p=0.019), in favour of exercising into the hypermobile range (n=11) compared to neutral only (n=14). Conversely, parent-reported overall physical health significantly favoured exercising only to neutral (p=0.037). No other differences were found between groups and no adverse events occurred., Conclusions: Parents perceive improved child psychosocial health when children exercise into the hypermobile range, while exercising to neutral only is perceived to favour the child's physical health. A physiotherapist prescribed, supervised, individualised and progressed exercise programme effectively reduces knee pain in children with JHS., Trial Registration: Australia & New Zealand Clinical Trials Registry; ACTRN12606000109505.